Abnormal external genital development is a common clinical sign of abnormal sexual development disorders, usually the enlargement of the clitoris and the fusion of the labial sac. Because of the great psychological impact of vulvar confusion on the patient and the inability to live normally in society, plastic surgery is required to change to a female vulva or plastic surgery to a male, depending on the situation. However, in this article, we will mainly discuss the surgical change of the vulva into a female vulva through abnormal vulvar development. For enlarged clitoris, the traditional procedure is simple clitoridectomy. Since the clitoris is an important organ related to the quality of sexual life, excision brings a great impact on the patient’s quality of life. In order to change the disadvantages of this procedure, Spence and Allen proposed a neurovascular preservation clitoral reduction in 1973 [1], and in 2003, Lang Jinghe et al. detailed the key points of this procedure.2 We have improved this procedure and it has become a routine procedure for the treatment of clitoral enlargement. The procedure is safe, aesthetically pleasing, and more in line with anatomy and physiology. The type of vulvar malformation and anatomical features of vulvar malformation is most commonly confused by congenital adrenocortical hyperplasia, and Prader classified different degrees of vulvar masculinization into five types [4]. Type IV has an enlarged clitoris that resembles a penis, with the urogenital sinus opening at the base of the penis, resembling hypospadias, and a fused genital bulge. When the clitoris is significantly enlarged, its internal structure resembles that of the male penis, with the two penile corpus cavernosum separating on either side posterior to the pubic arch, each attached to the anteromedial aspect of the right and left pubic sciatic branches. The enlarged clitoris is rich in blood, lymph and nerves. The distribution of blood vessels is divided into superficial and deep groups, the superficial group being mainly the dorsal clitoral artery located on the dorsal aspect of the clitoral body and the deep group from the vaginal artery. The main afferent nerve is the dorsal clitoral nerve, which is distributed in a fan shape throughout the clitoral body, but the head and the dorsal area are the most dense, which facilitates the transmission of sexual stimulation [5]. The sexually sensitive area is located at the head of the clitoris. Based on the above anatomical features, the basic objectives of surgery for patients requiring vulvoplasty for women should be: (i) clitoral body excision with preservation of vascular nerves; (ii) preservation and reduction of the clitoral head; (iii) establishment of normal labial structure; (iv) ensuring adequate vaginal length and large enough vaginal opening; and (v) separation of urethra and vagina to prevent urinary complications [6]. The basic principle of surgery is to try to restore the normal anatomical structure and preserve the original sexual function as much as possible. Second, historical review There are various surgical approaches to clitoroplasty. The earliest, in 1930 by the United States Hugh Hampton Young proposed [7]. 60s, the main surgery for the clitoral head retained, the clitoral body buried under the skin clitoral burial method or clitoral shortening buried method [1], but this surgery often cause severe local pain, when congestion local bulge obvious, affecting the aesthetic. In the late 1970s, the conventional procedure was clitoridectomy [7]. This is a simple procedure, but the normal anatomy and aesthetics are lost and sexual function is affected. It has been reported that 78% of patients who underwent clitoridectomy at an early age lacked sexual desire and 39% were unable to achieve orgasm as adults [7]. In 1973, Spence and Allen proposed clitoral reduction with preservation of neurovascularity [1]. The surgery not only preserved the vascular nerves but also part of the clitoral head and the preserved prepuce formed the labia minora, these made the vulva more in line with normal anatomy and physiology and preserved the sexual function as much as possible. In the application of this surgery, before cutting the skin on the back of the clitoral body, saline is injected in the whole subcutaneous layer to form a water cushion, which is easy to separate and bleeds less, and avoids damage to the vascular nerves. Indications for surgery: congenital adrenocortical hyperplasia, incomplete androgen insensitivity syndrome, testicular degeneration, true hermaphroditism, etc. When the patient has signs of clitoral enlargement or labial capsule fusion, vulvar plastic surgery is required. The first step is to inject saline widely into the superficial subcutaneous fascia of the enlarged dorsal clitoris to form a water cushion under the clitoral skin (for patients without hypertension, 4 drops of norepinephrine can be added to 100 ml of saline). After the skin is cut, the skin and superficial subcutaneous fascia are sharply separated on both sides of the incision, taking care not to damage the skin. The lateral aspect of the clitoral corpus cavernosum is separated to fully expose the corpus cavernosum, see Figure 2. The dorsal aspect of the supraclitoral artery and nerve and its surrounding tissues are bluntly separated from the lateral middle of the corpus cavernosum, see Figure 3. It is important not to damage the vessels and to preserve as much of the nerve as possible during the separation. The cavernous body between the proximal part of the coronal sulcus and the root of the clitoris is excised, and the root is excised close to the two descending branches of the pubic arch, with sutures to stop bleeding. The clitoral head is fixed at the root of the subpubic bone with a median suture on each side of the clitoral head, see Figure 4. The dorsal median skin of the clitoral head is sutured together with the median incision marked at the beginning of the procedure with a No. 4 silk suture, and the rest of the preserved clitoral skin is pulled down along the dorsal cut edge to form the labia minora, with interrupted silk sutures along the cut edge of the skin, see Figure 5. If the clitoral head is too large, a wedge-shaped incision can be made to remove part of the clitoral head and suture the wound, see Figure 6. In 1999, we reported 16 cases of congenital adrenocortical hyperplasia in which the clitoris was reduced and repositioned with preservation of the vascular nerves. Twelve of these cases were married, five were pregnant, and four were fertile. Eight cases were followed up with satisfactory clitoral sensitivity. The surgical technique is now well established, with an average operative time of 60 minutes and bleeding of 10-20 ml. No intraoperative or postoperative complications such as hematoma occurred in any case. At short-term follow-up, the appearance of the vulva was good and aesthetic, and the patients were basically satisfied. Since the operation was performed, the surgical approach has been improved, the steps have become clearer, and the operation time has been significantly shortened, from about 3 hours at the beginning to 1 hour at present. Since 2000 to date, more than 60 surgeries have been completed, with good postoperative follow-up and patient satisfaction. The clitoral reduction repositioning with preservation of vascular nerves is a rare but easily mastered surgical procedure after training, and there are no cases of surgical failure as long as the standard surgical steps are followed. Since the majority of gynecologic clinicians have not been exposed to it, it is necessary to introduce and promote it among clinicians in order to better serve patients.